Hanif Kureishi, venting his anger and dismay at the focus of the recent European elections, argues that the migrant is portrayed and positioned as ‘a zombie in a video game, he is impossible to kill or finally eliminate not only because he is already silent and dead, but also because there are waves of other similar immigrants just over the border coming right at you…’. In times such as these, he argues what is normal is that ‘the migrant is degraded to the status of an object about whom anything can be said and to whom anything can be done’ (‘The migrant has no face, status or story’, Guardian 20.05.14).

Yasmin Gunaratnam, in her Death and the Migrant takes us back to what feels like a better time, maybe only a few months ago it seems, when migrants were not so openly denigrated and politically used, before, in Kureishi’s words they were ‘deposited outside the firmament of the acceptable’, when the sharing of experiences of existentiality seemed possible. Different times, yet both Gunaratnam and Kureishi draw on death, in meaning and representation to focus our attention on how the migrant can be both present and absent in daily discourse and social practices. Death, that ultimate threat to security and sense of belonging is used by both to explore what divides UK society, but in contrasting ways.

Gunaratnam has for some time been interested in exploring the links between migration, illness and care; ‘diasporic dying’ (p xiii) in her words after personal experience led her into the world of the palliative care movement and its institutions. Care systems in the UK today and from the beginnings of the National Health Service and in the private and voluntary sectors would be unworkable without the presence of migrant care workers and medical professionals, she insightfully turns the tables and uses migrant experiences of death and bereavement to explore the impact of difference within those institutions which manage terminal care.

While she writes of how dying points to a ‘shared human susceptibility’ (p 4) she also argues that this common experience introduces the potential to ‘derail dominant ideas and narratives about migrants by showing something of our singular differences and our humanity’ (p 8). Drawing on Derrida’s notion of the foreigner she disruptively introduces migrant experiences of death as breaching borders within the palliative care process, as practices are challenged by personal stories and end of life choices which not only reveal that, as she says, ‘Migrants die’ but that their last journey is marked by ‘the very conditions of migration – movement, improvisation and uncertainty’ (p 12).

Her methods are very different to Kureishi’s angry call. Using an oral history approach, images, her own poetry and an ethnography which brings the reader close to the physicality of dying, she presents in what she describes as a ‘mixed method approach’ a ‘chorography’ (p. 17) of the stories, the bodies and the words of migrants. No blank zombie apparitions here but people living with dying and with the management of their last days. And these are, paradoxically, privileged people for palliative care within and without the hospice is ‘”A bit of heaven for the few”’ (A bit of heaven for the few? an oral history of the modern hospice movement in the United Kingdom, Clark et al, 2005). Hospice care is available only for a minority of deaths despite care of the dying practices having spread beyond the walls of hospices. A recent report reveals a lack of training in palliative care amongst doctors and nurses with fewer than half of patients in NHS hospitals in one study being told that they were dying (National care of the dying audit for hospitals England, Royal College of Physicians, May 2014). The people and the care that Gunaratnam presents are unique but as they experience palliative care they also experience the ‘…unconditional hospitality of hospices as a community of the unalike’ (her emphasis, p 90). That sense of community amongst death was something that Cicely Saunders (figure 1), doctor and acknowledged founder of the modern UK hospice movement was seeking when she began to develop her ideas about end of life care in the late 1940s, opening the first modern hospice, St Christopher’s in Sydenham, south-east London in 1967.

Figure 1 Nadia Bettega Cicely Saunders bust, St Christopher’s Hospice

Dame Cicely, as she later became, might scarcely recognise the patient lives and caring practices Gunaratnam sets out in her book. For one thing she was a devoted Christian, evangelical, but not closed off so much in her thinking that she was unable to be affected by the request of David Talsma a dying young Jewish migrant Holocaust survivor, for the truth about his condition. What developed between them during his last days, as Gunaratnam suggests, was a deep emotional and spiritual love. This experience led Cicely Saunders to argue for, and to teach and practice, ways of working with dying people which demanded openness and a breaching of conventions with respect to pain management, choice and ways to live amongst death.

Each chapter in Death and the Migrant is an elegant and emotion fed essay, drawing on the words of dying people and of those caring for them as they try to arrive at some kind of resolution while illness progresses rapidly and abilities to communicate verbally and non verbally diminish. Some people speak directly in voices which are set in context by Gunaratnam’s appreciation of their condition. Thus, Maxine Lewis, a retired nursing auxiliary, mother to 10 children, 3 dead in infancy, is shown as an active resister in her current situation. First the observer’s voice:

In the last days of her life Maxine Lewis was a mess. Her face was
streaked with the residue of mucus from her eyes, nose and mouth. A
rancid musty odour encircled her bed. Professional negligence was
not the cause of this neglect. Neither was staff shortages or budget
cuts.

Then we have Maxine’s words:

De nurse have time for me you know Yasmin. But I push er away every
time she come wash me. She ball at me, an I don’t like people frighten
me. I’m tired of people proddin an poking at me all de time (p 44).

Maxine had been a nurse herself so she knew what effect she was having on the people around her but she didn’t want any longer to be treated ‘like a donkey’ (p 45), so she was resisting, bucking the system in her own way. She was doing this with humour too, but aware of the racism that surrounded her, the only black woman in a six bedded ward, choosing a ‘dirty death’. Gunaratnam, in the same chapter includes transcripts of the care practitioners, in this case the hospital social workers. They too have insights:

I think particularly when you’re touching people, you know as nurses touch, and I think for black people who perhaps have never been touched by a white person, or only attacked, I think that must be particularly, particularly, er, complex, you know, it really needs talking about really.

Gunaratnam’s mixed methodology shows how people’s biographies help to breach the gaps between talk and touch and with her keen and sensitive skills of observation and ability to communicate what she smelled, heard and felt, she centres the migrant body as it breaches borders of care and communality within the personal transience of a setting given over to the dying. In their own homes, patients who are being given palliative care are able to organise their present lives in ways that can be explained through their past while showing that they also have a mind for the present and the future (Figure 2).

Figure 2 Nadia Bettega End of life care in the home

Edwin lives on his own in a council flat in south London, his wife now lives in a nursing home and he copes on his own, preferring to sleep on the settee rather than in the bedroom. He can talk about coming from Jamaica to work in the 1960s and though his sons live in London he doesn’t expect to see them, they have lives to get on with. So, he sleeps in his living room, but not because he cannot bear the sight of the bed he now cannot share with his wife but because the pills he takes for his advanced prostate cancer mean that he has to get up very often in the night. The settee is more convenient in height and he can just use a bucket. He’s encircled by what is familiar ‘in his furnishings and routines’. In her poem, ‘The Prince and the Pee’ (formerly ‘The Bed’) Gunaratnam presents a closer focus on how she sees Edwin’s apparent compliance with his situation:

In the shadows of nightfall
He feels the knife.
This time in his heart
quivering, shimmering.
In this place of dislocation
Contorted emasculation
He marks his loss. Silently,
with the truth.
Rolling saltiness around his mouth
he leans forward slowly
pisses into the bucket.

Relieved.

Death and the Migrant is replete with similarly sympathetically drawn stories, linked with the history of the palliative care movement to illustrate how the accomplishment of successful dying depends on invention and the breaching of conventions, both social and medical. The crossing of boundaries which migrants effect in life presents the ultimate questioning of what it means to be a foreigner, embodying Derrida’s notion of disturbance, educating others about the limits to what can be known.

Gunaratnam’s rich and eloquent study of migrant death within the context of palliative care provision sustains that unknowability in ways that are entirely fruitful and necessary. Rather than evoking the imagery of the zombie her migrants are living and active participants in the care they receive, determining within the limitations of their conditions how they want their lives to end. In such ways, she and her research participants shift and illuminate understanding of both death and the migrant. This book deserves a wide readership, amongst students of death and dying, of migration, race and racism but perhaps for everyone who has contemplated how death is to be accomplished without compromising understanding of individuality in life.